Manual Therapy of The Thoracic Region

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PROF.UMASANKAR MOHANTY

B.P.T ( Hons), M.P.T( Manual Therapy), PhD, M.I.S.E.P,M.I.A.S.P, F.A.G.E                        

Founder President, Manual Therapy Foundation of India www.mtfi.net

An ant on the move does more than a dozing ox.

                                                                                     Lao Tzu

Anatomy And Biomechanics Of The Thoracic Region:

The thoracic spine is the longest part of the spinal column and is considered a transitional zone between the cervical and lumbar spine. The region is unique because of the size and extent of the region and the articulations with the rib cage. The articulations with the rib cage lead to regional variations in movement patterns and function (Willems JM, Jull G 1996). The thoracic region has least mobility, prime  reason being the presence of the vital visceral organs and the thinness of the Intervertebral discs in the thoracic region.

Thoracic region comprises of 12 vertebrae,  they are intermediate in size between those of the cervical and lumbar regions; they increase in size as one proceeds down the spine, the upper vertebrae being much smaller than those in the lower part of the region. They are distinguished by the presence of facets on the sides of the bodies for articulation with the heads of the ribs, and facets on the transverse processes of all, except the eleventh and twelfth, for articulation with the tubercles of the ribs ( Fig.1).

Several anatomical components control or contribute to the available movements of the thoracic spine. The Intervertebral disc plays a major role in movement control

of the thoracic spine, a much more significant role than the posterior structures (Edmondston SJ, Singer KP 1997). With respect to height, the disk in the thoracic spine shows less height in ratio to the vertebral body than the cervical and lumbar spines (Kapandji I,1978). In addition, the thoracic disk has a relatively small nucleus pulposus (Galante JO,1967).

Thoracic Spine

Osteokinematic degrees of freedom:3 motions: Forward/backward bending Side bending Rotation
Ligaments:Anterior longitudinal ligament Posterior longitudinal ligament        Supraspinous ligament Interspinous ligament  Ligamentum flavum Intertransverse ligament
Joint orientation:Caudal facet of cranial vertebra: Ventral caudal, medial  Cranial facet of caudal vertebra: Do cranial, lateral Cranial vertebral body: Caudal Caudal vertebral body: Cranial
Type of joint:Facets: Synovial Disc: Amphiarthrodial
Articular surface anatomy:Ovoid, plane Cranial facet: Convex Caudal facet: Concave
Resting position:Midway between flexion and extension
Close-packed position:Full backward bending
Capsular pattern of restriction:Side bending = rotation > back bending

Movements of The Thoracic Spine:

Movement                                                      Normal Range (Degrees)

   Flexion                                                                     90

   Extension                                                                 30

   Lateral flexion                                                          30

(Left and right)

Rotation                                                                      60

            (left and right)

(Adapted from Murtagh and Kenna, 1997)

In the zygapophyseal joints the superior articulating facets are slightly convex and the inferior articulating facets are concave.The superior articulating facet surfaces face posterior, lateral and cranial. The inferior articulating facet surface face anterior, medial and caudal.

Biomechanical coupling is 3-dimensional (3-D) and takes place within 6 degrees of freedom, where the vertebrae can translate along or rotate about each orthogonal axis((Panjabi M, Hult,1992). The 3-D motions in human vertebral segments correspond to flexion/extension, rotation and side-bending (lateral flexion) forces; one specific movement initiation (such as side-bending) theoretically activates movement in the other component motions. This coupling behavior is dependent on the first motion of initiation (ie, side-bending), the posture of the spine, and the pathology of the segment (Panjabi M, Yamamoto I,1989).

PHYSICAL EXAMINATION OF THE  THORACIC REGION: –

ACTIVE MOVEMENTS WITH OVER PRESSURES:

The subject is in high sitting position. The clinician performs overpressures after active movements of flexion, extension, lateral flexion ,rotation, compression and distraction.

If the pain is perceived in flexion it suggests pariarticular tightness or injury. (Fig.2)

If the pain is perceived in extension, it suggests articular involvement. ( Fig.3)

If the pain is perceived in lateral flexion of ipsilateral side suggests articular involvement; pain in contralateral side of lateral flexion suggests pariarticular tightness or injury. ( Fig.4)

If the pain is perceived in rotation to ipsilateral side it suggests articular involvement; pain in contralateral side suggests pariarticular tightness or injury. ( Fig.5)

If the pain is perceived in compression, it suggests articular involvement.

If the pain is reduced in distraction, it suggests articular involvement. If the pain accentuates in distraction it suggests pariarticular tightness or injury. 

Palpatory Landmark of the Thoracic region: –

  1. Inferior angle of scapula corresponds to T₇ spinous process.
  • Spine of scapula corresponds to T₂-T₃ junction.
  • From spinous process about  ½ inch lateral one can palpate for the zygapophyseal joint deep inside the erector spinae muscle.
  • From spinous process about 1 inch lateral one can palpate for transverse process of thoracic spine.
CLINICAL TESTS FOR THORACIC REGION

The following are some of the important clinical tests of  Thoracic Region.

  1. Rib Compression Test ( Fig. 6)

Subject’s Position: High Sitting

Clinician’s position: Stands posterior to the subject.

Procedure: The clinician places forearms on either side of the lateral margins of the subject’s rib cage.  Pressure is applied with the forearms, squeezing the patient’s chest.

Rationale: The pressure caused by approximating the hands increases stress at the sternocostal, costotransverse, and costovertebral margins.

Clinical Significance:

Localized pain at the sternocostal, costotransverse, or costovertebral margins indicates a subluxated rib at the point of pain.

If the patient feels pain along the shaft of a rib, that rib may be fractured.

  • Soto-Hall Test ( Fig. 7)

Subject’s Position: Supine lying

Clinician’s position: Stands at the head end of the couch.

Procedure: The clinician places one hand on the patient’s sternum. The patient’s  occiput is supported and gently the chin is taken for flexion to  the chest.

Rationale: This test places traction along the posterior supraspinous ligaments. When the level of vertebral injury is reached, a noticeable local pain results.

Clinical Significance: Local pain within the cervical or dorsal spine to the level of T7 may indicate fracture at the level, or a ligamentous sprain.

  • Spinous Percussion Test ( Fig. 8)

Subject’s Position: High Sitting position.

Clinician’s position: Stands posterior to the subject.

Procedure: The clinician strikes the spinous processes of the thoracic region using neurological percussion hammer. The striking is performed to the paraspinal musculature also.

Rationale: Any irritation of the spinous processes and surrounding  tissue is exacerbated by this test.

Clinical Significance: In case of  fractured vertebral segment a localized pain is felt.

In case of a disc lesion, the radicular pain increases.

In case of a ligamentous sprain a local nonradiating pain is experienced.

An increase in paraspinal pain on percussion may indicate muscular strain.

  • Sternal Compression Test ( Fig. 9)

Subject’s Position: Supine lying.

Clinician’s position: Stands at thehead end of the couch.

Procedure: The clinician applies pressure on the patient’s sternum with the palms of both hands.

Rationale: Downward pressure on the sternum will increase a bowing of the ribs at the lateral margin. Also, separation of the rib along the sternocostal junction can occur.

Clinical Significance: Localized pain in the lateral areas of a rib may indicate fracture at the point.

Localized pain at the sternocostal junction may indicate a subluxated or disarticulated rib.

  • Tuning Fork Test ( Fig.10)

Subject’s Position: The subject is in high  sitting position.

Clinician’s position: Stands posterior to the subject.

Procedure: The clinician places stem of the 128-cc tuning fork on the spinous processes.  

Rationale: The vibration caused by the tuning fork is transferred to the bony prominence being evaluated. If there is fracture, the underlying vibration tissue will cause the two ends of the fracture to rub.

Clinical Significance: An increase in sharp pain at the area of the bony prominence being tested is positive for fracture. This is a good way to test for fracture if radiography is unavailable.

A subtle hairline fracture may cause only a slight increase in pain at the site being evaluated

MANUAL THERAPY OF  THORACIC REGION

  1. CENTRAL P-A GLIDE ( MOBILISATIONS AND MANIPULATION) (Fig.11)

Subject’s Position: Prone Lying.

Clinician’s position: Lateral aspect of the couch

Procedure: The clinician places the hand (pisiform contact) on the spinous process.

Posterior to anterior glides are applied.

For upper thoracic ( T1-T3) with 60 degrees angulation in respect to the transverse plane

For mid thoracic ( T4-T9) with 80 degrees angulation in respect to the transverse plane

For low thoracic ( T4-T9) with 0 degrees angulation in respect to the transverse plane.

The glides can be applied for 10-15 times .

In case of pain ( Grade I and II are applied) and in  stiffness ( Grade III and IV applied)

Grade V thrust can be applied in same angulation.

Clinical Significance: The mobilization and manipulation techniques are useful for releasing the affected segment/region. 

  • LATERAL P-A GLIDE ( Fig.12)

Subject’s Position: Prone Lying.

Clinician’s position: Standsat the  lateral aspect of couch.

Procedure: The clinician places the pulp of the thumbs on the facet joint ( ½ inch lateral from the midline)

The glides are applied for 10-15times.

In case of pain ( Grade I and II are applied) and in  stiffness ( Grade III and IV applied)

The Lateral PA glides are also applied to the transverse process ( 1 inch lateral from the midline)

The Lateral PA glides are also applied to the rib ( 1and ½  inch lateral from the midline)

Clinical Significance: The technique is useful to treat the facet joint and costo-transverse joint dysfunctions.

  • TRANSVERSE  GLIDE  ( Fig.13, Fig.14)

Subject’s Position: Prone Lying.

Clinician’s position: Standsat the  lateral aspect of couch.

Procedure: The therapist places the pulp of the thumb is placed at lateral aspect of the spinous process, thumb of the other hand reinforces the thumb in contact. The glides are applied for about 10-15 times.

Clinical Significance: The technique is useful if there is rotation around the y-axes and the technique is applied opposite to the side of rotation so that it returns to the neutral position.

  • MANIPULATION CROSSED HAND ( ROTATION GLIDING, PATIENT PRONE, SHORT LEVER TECHNIQUE) ( Fig.15, Fig.16)

Subject’s Position: Prone Lying.

Clinician’s position: Standsat the  lateral aspect of couch.

Procedure: The therapist palpates for the transverse processes of the stiff segment in thoracic region. The therapist places the pisiform over the diagonal transverse processes. In order to clear the longissimus muscle the hands are moved in anti clockwise direction by 90 degrees. The therapist reaches for the barrier and the thrust is applied postero-anterior.

Clinical Significance:

This technique is extremely useful to treat hypomobility and stiffness of the thoracic region.

 5.RIB MOBILISATION ( Fig. 17, Fig.18)

Subject’s Position: Prone Lying

Clinician’s position: Stands at the lateral aspect of the couch.

Procedure: The clinicianplaces the radial aspect of the index at the angle of the rib.

The glide is applied in antero-lateral direction 10-15 times.

Clinical Significance: The glide is extremely useful for the treatment of rib dysfunction.

6.RIB MANIPULATION ( Fig.19)

Subject’s Position: High Sitting position with the arms crossed and placed on opposite shoulder. 

Clinician’s position: Stands posterior to the subject.

Procedure: The clinician places thepisiform at the angle of the rib.

The thoracic region is taken for extension, side flexed to the ipsilateral side and rotated to the contra lateral side.

The thrust is applied anterior, superior and lateral.

Clinical Significance: This technique is applied to relocate the subluxated rib.

CONCLUSION:

Manual Therapy techniques are extremely useful for the treatment of the thoracic region and shoulder complex mechanical dysfunctions. A biomechanical approach to treatment of the thoracic region requires an understanding of  its anatomy,biomechanics and pathomechanics. The clinician must do thorough examination and clinical reasoning before applying the skillful manual therapy techniques.  

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